Request a one-time Premium Payment from My Bank Account
We will draft the requested amount within the next three business days.

Please provide your Client ID:

First Name:                                      Last Name:

Your Email Address:

Phone Number:

Name of group or individual on billing invoice:

By selecting this option, I (we) hereby authorize Wolfpack Insurance Services Inc. to charge the applicable monthly dues to my account designated below.  I understand the coverage will only become and remain effective if there are sufficient funds at the time of the deduction.  This authority to deduct funds from my account is for this one draft only and will not be a monthly recurring payment.  (You will have the option of selecting a monthly automatic withdrawl at the end of this form.)  My bank is authorized to make corrections if any should be necessary.  

I (We) acknowledge that the origination of ACH transaction to my (our) account must comply with the provision of U.S. Law and the Rules of the National Automated Clearing House Association. I (We) further acknowledge that I (we) have retained a copy of this authorization when I (we) signed it.
You hereby authorize and request Wolfpack Insurance Services, Inc. to debit funds from your account at the financial institution indicated, and credit the funds according to the above instructions. Funds need to be on deposit at the designated financial institution on the evening prior to the effective date of the ACH debit. In the event of an error, you authorize  Wolfpack Insurance Servcies, Inc to take any and all action required to correct the error.
You must notify Wolfpack Insurance Services, Inc.  in writing if you would like to make any changes or to cancel the authorization.
You agree to indemnify and hold Wolfpack Insurance Servcies, Inc. harmless from all costs, including attorney’s fees, (to the extent permitted by law), damage or claims related to Wolfpack Insurance Services action in refusing payment of the item, including claims of any joint account-holder, payee, or endorsee, or in failing to cancel or process an item as a result of incorrect information provided by you.   Upon cancellation Wolfpack Insurance Services will collect any outstanding premium due.
 By clicking Submit Form below, you certify that the information you have given on this ACH Debit Authorization Agreement for Direct Payments is complete, true, and submitted for the purpose selected above.

Automatic draft failures are subject to a $15.00 fee.

Name as it appears on the Bank Account:

Bank Name:

Choose Checking or Savings:
Choose the Type of Account:

ABA Routing Number:

First nine digit number on left hand bottom of your check

Account Number:

Second series of numbers on the bottom of the check

Funds will be drafted within the next three business days.
Your bank statement will reflect an automatic draft to "Wolfpack Ins"

Premium Amount Due:

Leave this blank if you want us to calculate the amount due.

This pays the premium through the month of:

I would like to set this up as an automatic monthly premium payment.
Automatic drafts will occur on either the 15th or the 25th of the month prior to the month of coverage.  Trust Group clients are drafted on the 25th of the month prior to the month of coverage.  All others are drafted on the 15th.  

By indicating YES on this question you are accepting the conditions listed on this form.
Yes, Please set this up to be a monthly automatic payment
No, Please just draft the funds this time only